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VADM WlUaid P. Arentzen, MC, USN 

Surgeon General of the Navy 

RADM H.A. SpariiB, MC, USN 
Deputy Surgeon General 

Director of Pablic Affairs 

ENS Richard A. Schmidt. USNR 


Jan Kenneth Hennan 

Assistant Editor 
Virginia M. Novinsici 

Editorial Assistant 

Nancy R. Keesee 

CoDlrtlrating Edlt»r« 

Contributing Editor-in-Chief: CI>R EX. Tay- 
lor (MC): Aerospace Medicine: CAPT M.G. 
Webb (MC): Dental Corps: CAPT R.W. 
Koch (DC): Education: LT R.E. Bubb (MSC); 
Fleet Support: LCDR J,D, Schweitzer (MSC); 
Gasiroenierohgy: CAPT D.O. Casiell (MC); 
Hospital Corps: HMCM H.A. Olszak; legal: 
LCDR R.E. Broach (JAGC); Marine Corps: 
CAPT D.R. Hauler (MC): Medical Service 
Corps: CAPT P.D. Nelson (MSC); Nepkrol- 
og)\ CDR J.D. Wallin (MC); Nurse Corps: 
CAPT M.F. Hall (NO; Occupational Medi- 
cine: CDR J.J. Bellanca (MC); Preventive 
Medicine: CAPT D.F. Hoeffler (MC): Re- 
search: CAPT J. P. Bloom (MC): Submarine 
Medicine: CAPT R.L. Sphar (MC) 

raUCY: vs. Navy Mtdioint ix u official publiaokm 
of the Ntvy McilicBt Dcf^ulmem, published by the Buieaa 
of Medictae and Surgery, h 4i&&eniiii«H to Na^^ Medical 
DcpaTliDcnt per&onne] official and pn^fc^sional inforniaticiD 
relative ro mediciae. dentistry, and the allied heahh sci- 
ences. OpinicMis expressed are those of the authors and do 
not necessarily represent the official positioD of the Depart- 
menl of the Nb>t. the Bitrcau of Medkinr and SutKCry. or 
any other governmental tjeparlment or a^ncy. Trade 
tunies are used for ideotifkaliott only and do not represent 
an endorsement by the Department of the Navy or the Bu- 
reau of Medictne and Surgery. Although U.S. Savy Medi- 
cine may cite of extract fttjni directives, official authority for 
action should be obtained from the cited reference. 

DISTRIBUTION; U.S Naty Medicine is distributed to 
active. duly Medical Department personnel m the Standard 
Navy Distribution List. The following distribution is author. 
i^ed: one copy for each Mt^ical. Detital, Medical Service 
and Nurse Corps officer: one copy for every 10 enlisted 
Medical EXepartment members. Requests to increase or de- 
crease the number of allotted copies should be ftrrwarded to 
U.S. Naiy Ktedicixe via the local coininand. 

CORRESPONDENCE: All cormpondeaee should be 
addressed to; Editor. U.S. Navy Medicine. Department of 
the Navy. Bureau of Medicine and Surgery {Code 0010). 
Washington. O.C. 20372. Telephone: (Area Code 202) 254- 
42SJ. 254-431(., 2S4-4214; AutOvXiB 2*t-42S3, 2M-43I6. 29*- 
4214. ContnbutKms from the field are welcome and will be 
published as space permits, sobject to editing and possble 

The isitiaace of this pablkstioa is approved in accortlance 
with Department of the Navy Ptibfications and Prinliii^ 
Regulations (NAVEXOS P-JS). 


Vol. 70, No. 5 
May 1979 

1 From the Surgeon General 

2 Department Rounds 
Comic Relief Down Under 

4 Notes and Announcements 

6 Interview 
RADM Conder Retires 

9 Features 

Adverse Health Effects of Smoking and the Occupational Environ- 

10 BUMED Completes Reorganization 

18 Independent Duty 

Asbestos-Related Diseases 
CDR J.J. Bellanca. MC, USN 

20 Professional 

Roentgenographic Findings of Asbestos Exposure 
CAPT J. P. Smith. MC, USN 
CAPTC.W. Ochs, MC, USN {Ret.) 

24 Sampling for Airborne Asbestos Fibers 
R.R. Beckett 


COVER: Removal of asbestos from the frigate USS Ainsworth at the 
Philadelphia Naval Shipyard. One member of the rip-out crew han- 
dles a vacuum hose connected to the pierside vacuum unit and sprays 
the work area with water mist. 




Continuing Education for the 
Navy Medical Department 

Continuing Education for all Navy 
Medical Department health care 
providers is an absolute necessity. 
All our corps officers — Medical, 
Nurse, Dental, and Medical Service 
as well as physician's assistants 
must be conversant with updated 
quality information in order to 
maintain a high standard of medical 
service and support for the benefi- 
ciaries of the Navy health care sys- 
tem. The rapid development of con- 
tinuing education requirements for 
specialty board recertification, pro- 
fessional society membership, and 
the requirements of the Joint Com- 
mission on the Accreditation of 
Hospitals, must be fulfilled in order 
to document professional compe- 

Since 1976, conference travel 
funds have been increased signifi- 
cantly . I am well aware that the total 
amount is not yet adequate to pro- 
vide each and every individual a 
conference of his choice, and that 
the amount of funds available has 
not paralleled the increased costs of 
travel, per diem, and tuition. 

This imposed deficit requires 
each of us to employ ingenuity and 
creativity in making use of available 

resources in order to meet continu- 
ing education requirements. Strong 
ties with local professional societies 
and universities, local guest lecture 
series, and the use of local com- 
mand expertise can greatly aug- 
ment our educational efforts. It 
should be policy to make wise use of 
conference dollars by limiting un- 
necessary travel and excessive tui- 

Continuing education programs 
should be designed to make them 
appropriate to the Naval Regional 
Medical Centers' patient care needs 
as well as the individuals' profes- 
sional educational requirements. 
Local command educational efforts 
should supplement but not replace 
outside education programs. 

I assure you that every effort is 
being made to increase our profes- 
sional conference travel resources 
to meet the educational require- 
ments of our professional staff, 

I request your cooperation and 
assistance in developing a high 
quality continuing educational pro- 
gram that will supplement the edu- 
cational needs and requirements we 
must continue to meet under the 
present constraints. 

Assistance in developing your 
programs can be obtained by con- 
tacting the Naval Health Sciences 
Education and Training Command. 




Vice Admiral, Medical Corps 

United States Navy 

Volume 70, May 1979 


Comic Relief Down Under 

At the remote Naval Communica- 
tion Station, Harold E. Holt, in 
Exmouth, Western Australia, a 
team of Navy wives and active duty 
personnel are donating their time 
and talents to brighten the base dis- 
pensary walls with beloved cartoon 
characters. The facility, on the 
Northeast Cape, is approximately 
800 miles north of Perth and far 
removed from any of the conven- 
iences and resources most Navy 
commands are able to rely upon. 
But the initiative, imagination, and 
talents of its military and civilian 
personnel certainly have not failed 
to meet the challenge. 

The dispensary had just received 
a fresh coat of paint from the base 
Public Works Department, but 

U.S. Navy Medicine 

senior medical officer, LT David 
Detert, MC, realized that the job 
was more utilitarian than decora- 
tive. Something was needed to lift 
the spirits of people coming in for 
medical attention. 

The answer was a self-help 
project calling for special talent. Dr. 
Detert challenged the Officers' 
Wives' Club with decorating the 
walls. Both the club and the medical 
department agreed to paint familiar 
cartoon characters, as these would 
be bright, cheery, and distracting, 
especially for young patients. 

The club used the base news- 
paper and word of mouth to recruit 
people to draw the larger-than-life 
figures. Public Works supplied the 

Three Navy wives volunteered to 

draw and the editor of the base 
newspaper volunteered her efforts. 
Before long. Road Runner appeared 
in the waiting room and Charlie 
Brown and Lucy marked the loca- 
tions of the appropriate restroom 
doors. Other cartoon characters 
materialized. Under the pharmacy 
windows, the Count leered as he 
held a prescription and a bottle of 
pills. A big molar with a toothbrush 
appeared near the dental treatment 
area. Other treatment areas were 
represented by a sick Cookie Mon- 
ster, Donald Duck, Bugs Bunny, 
Big Bird, Snoopy, Woodstock, and 
appropriately enough, a Tasmanian 

Those participating in the effort 
were Linda Dickerson, Diana 
Hamel, Jan Parneil, Sandy Shaw, 

Barbara Smith, Barbara Unterzu- 
ber, Kitty Jackson, Terry Ventura, 
Dental Technician Nathan Catter- 
ton, and Journalist Second Class 
Laura Hansen. 

The project began in mid-Novem- 
ber and the work was done on week- 
ends and evenings to avoid disrupt- 
ing the dispensary routine. Never- 
theless, the artists completed the 
work by 21 December, when the 
dispensary's medical and dental 
departments hosted an open house 
for the base. 

In late January, the women 
returned to work to continue the 
project on some of the rear corri- 
dors. Their morale-boosting efforts 
are typical of the cooperation that 
makes the remote station seem a bit 
closer to home. 

Volume 70, May 1979 




Many articles by Navy personnel appear each 
year in a variety of professional journals and other 
publications. U.S. Navy Medicine would like to 
include a monthly list of some of these articles 
written by Navy authors from all corps. If you 
have published recently and would like to share 
your research or perceptions with your colleagues, 
please send us the title, name, and issue of the 
publication in which your article appeared. 


The Armed Forces Institute of Pathology (AFIP) of- 
fers one year of advanced residency training in the 
special field of forensic pathology. The residency is 
available to active duty medical officers of the Army, 
Navy, and Air Force, who are either diplomates of the 
American Board of Pathology in anatomic pathology 
(preferably in both anatomic and clinical pathology), or 
eligible to take these examinations. Positions are avail- 
able for the 1980-81 residency year. Interested persons 
should contact CAPT Robert L. Thompson, MC, USN, 
Department of Forensic Sciences, AFIP, Washington, 
D.C. 20306. Telephone: Autovon 291-3287, Commercial 
(202) 576-3287, 

Applications must be submitted by 15 Aug 1979 in 
accordance with BUMEDINST 1520. lOG and BUMED- 
NOTE 1520. 


A postgraduate course on Strategies of Care for the 
Cancer Patient will be held 13-14 July 1979 at the Del 
Monte Hyatt House, Monterey, Calif, 

The objective of this program is to assure the primary 
care physician's involvement as the key member of the 
treatment team for the cancer patient. The develop- 
ment of treatment strategies for both the clinical and 
psychosocial support of the cancer patient necessitates 
informed cooperation between the oncologist and the 
primary care physician. The continuum of care from 
risk determination through detection, treatment, and 
followup is an interdisciplinary effort that involves the 
primary care physician at every stage if the patient's 
treatment is to be "wholly successful." 

The program is accredited by the AMA Category I of 

the Physicians Recognition Award and the Certification 
Program of the California Medical Association. 

For more information write or call: Extended Pro- 
grams in Medical Education, University of California, 
Room 569-U, Third and Parnassus Ave., San Francisco, 
Calif. 94143. Telephone (415) 666-4251. 


If your hospital uses the IMED 922 Volumetric Infu- 
sion Pump, the Naval Health Sciences Education and 
Training Command (HSETC) recommends you borrow 
the new videotape IMED 922 Volumetric Infusion 
Pump, T-451, 09 min. It describes the use and 
operation of the pump for administering intravenous 
fluids on a semi-automatic basis. The new videotape 
was recorded to help hospital staff understand the 
theory and practical operation of the IMED pump and 
has helped train and give reinforcement training to 
medical personnel in the field. 

A videotape or film copy may be borrowed from 
HSETC Audiovisual Resources Division, Code 26, 
Bethesda, Md. 20014. Telephone Autovon 295-1226. 


From mid-April through October, the National Air 
and Space Museum will display artifacts relating to 
aerospace medicine. Items of interest will include 
WWII aircraft first aid and survival kits, post-landing 
survival equipment from the last Skylab mission, the 
current prototype of the Space Shuttle survival kit, and 
a model of the C9A Nightingale, the Air Force's flying 
hospital ward. The special mini-exhibit will be located 
on the first floor beneath the escalator nearest the 


On 30 March 1979, ground was officially broken for 
the Occupational Health Clinic, Naval Hospital, Cherry 
Point, N.C. The new facility will cost close to a half 
million dollars and will occupy 6,000 square feet. 


In April's Department Rounds, RADM Clinton H. 
Lowery's last assignment should have been listed as 
Commanding Officer, Naval Regional Medical Center, 
Camp Pendleton. We regret the error. 

U.S. Navy Medicine 


Regional Reflections became the first naval medical 
facility publication to be cited for a CHINFO Merit 
Award since 1975. The award is based on the monthly's 
demonstration of high standards of excellence and its 
significant contribution to the Navy's internal informa- 
tion goals. Congratulations to LTJG Francis C. Brown, 
MSC, Assistant Public Affairs Officer for the Medical 
Center, HM3 Mark S. Dilonno, editor, and their staff. 


The American Psychologist 34(1):56, Jan 1979, rec- 
ognizes the exceptionally outstanding career of one of 
the first Navy psychologists, Arthur L. Benton, Ph.D. 
Dr. Benton, who retired on 1 July 1978 as Professor of 
Neurology at the University of Iowa College of Medi- 
cine, received the American Psychological Association 
Distinguished Professional Contribution Award for 
1978, with the following citation: 

"He is a scholar who has done much to stimulate interest in the 
history of thought about the brain and its role in perception and cog- 
nition, an investigator whose research over the past 40 years has 
helped to erect a new discipline, the neuropsychology of human cog- 
nition. Arthur L. Benton is a leader and one of the principal architects 
of neuropsychology, giving it direction, attracting students from 
many fields, setting standards of objectivity and experimental control 
where subjective methods previously prevailed, bringing scientific 
discipline and a sense of optimism to the now burgeoning field. His 
interests are uncommonly broad, and his writings and forceful discus- 
sion in many areas have had important influence on the thinking of 
neurologists, psychologists, and psychiatrists both in this country and 
in Europe, Japan, and Australia," 

From 1941-1946, Dr. Benton served on active duty at 
several locations, among which were the Naval School 
of Aviation Medicine and the Naval Hospital, San Diego 
to which he was the first Navy psychologist assigned. It 
was in that assignment, with his early research on 
neurological and behavioral consequences of brain 
wounds, that Dr. Benton further established his life- 
long commitment to the field of neuropsychology. With 
more than 150 scholarly scientific publications, and 
numerous professional honors to his credit, it is an 
honor for the Navy Medical Department that Dr. 
Benton also holds the rank of Captain, Medical Service 
Corps, United States Naval Reserve (Ret.). 


Alcohol misuse can be a problem in the areas of work 
performance, safety, and individual health. The Navy 
is taking positive action by providing commands with 
a Navy Alcohol Safety Action Program (NASAP). The 

course will be conducted during off-duty hours, two 
nights a week, in three-hour sessions, for six weeks. 
The curriculum is designed to provide basic information 
and student awareness of alcohol, drinking problems, 
alcoholism, and related legal, medical, and social 
aspects. Completion of the NASAP course is considered 
to be "off-duty education" and the student is awarded 
3.6 continuing education units by the University of 
West Florida. 

Medical Corps officers can obtain a maximum of 36 
hours approved by the AMA Category I Continuing 
Medical Education. Nurse Corps officers are granted 36 
contact hours by the Continuing Education Approval 
and Recognition Program at HSETC. Dental and Medi- 
cal Service Corps officers and physician's assistants 
who successfully complete the curriculum may make 
applications to their respective professional associa- 
tions for continuing education credits. Hospital 
corpsmen will receive 3.6 continuing education units 
from the University of West Florida. 

NASAP locations and auxiliary classroom sites are as 

Alameda, Calif. 
Charleston, S.C. 
Great Lakes, 111. 
Hawaii, Pearl Harbor 
Jacksonville, Fla. 
New London, Conn. 

Norfolk, Va. 

Orlando, Fla. 
Pensacola, Fla. 
San Diego, Calif. 
Seattle, Wash. 

Washington, D.C. 

Auxiliary Site 

Barbers Point; Kaneohe Bay, Hi. 
Mayport; Cecil Field, Fla. 
Lakehurst, N.J.; Newport, R.L 
Portsmouth, N.H. 
Portsmouth; Oceana; Little Creek; 
Virginia Beach, Va. 

Whiting Field; Corry Station, Fla. 

Bremerton; Bangor; Whidbey Island, 


Bethesda; Patuxent River, Md.; 

Quantico, Va. 

Additional NASAP offices 
Camp Pendleton, Calif. Edzel, Scotland 

Guam, MI (NAVSTA) USS Forrestal 

Rota, Spain USS Saratoga 

Holy Loch, Scotland USS Gilmore 

Subic Bay, RP 

Anyone wishing to attend the Navy Alcohol Safety 
Action Program should contact the nearest NASAP of- 
fice. Additional information may be obtained by con- 
tacting: CDR G.A. Gunn, USNR, Program Coordinator, 
NASAP, Navy Alcohol Rehabilitation Center, Naval 
Station, San Diego, Calif. 92136. Telephone: Autovon 
958-2127/2128/2129 or LTJG C.A. Cole, MSC, USNR, 
HSETC Code 23-1, Bethesda, Md. 20014. Telephone: 
Autovon 295-0250. 

Volume 70, May 1979 


RADM Conder Retires 

The Seventy-First for the Nurse Corps 

This year marks the 71st anniver- 
sary of the Nurse Corps and the 
retirement of its director, RADM 
Maxine Conder. When U.S. Navy 
Medicine interviewed RADM Con- 
der during the Bicentennial year, 
she too was celebrating an impor- 
tant anniversary — her 25th year as a 
Navy nurse. Three years later we 
talked with her again about the 
Nurse Corps and her long, distin- 
guished Navy career. 

USNM: RADM Conder, since we 
talked with you in '76 there have 
been signiflcant changes hi the 
Navy health care field, most notably 
the regionalization and reorganiza- 
tion of BUMED. What has the 
Nurse Corps done to cope with 
these changes? 

RADM Conder: We have been 
forced to view our areas for per- 
formance beyond the four walls of a 
hospital. We expect our chief 
nurses or one of their representa- 
tives to make routine visits to all our 
dispensaries and clinics. Many of 
our nurses are now going aboard 

ships, perhaps for only a few hours, 
to conduct courses. Some of our 
men have been aboard carriers for 
as long as six weeks teaching and 
explaining the operation of sophisti- 
cated health equipment to medical 
personnel. Other Nurse Corps offi- 
cers routinely conduct CPR courses 
for entire crews. 

Also, if our doctors aboard ship 
get involved in surgical procedures, 
there will be a greater need for 
nurses. Having women assigned to 
shipboard duty may hasten a re- 
quirement for more nurse involve- 
ment aboard ship. 

What structural changes have 
been required to accommodate the 

We've identified billets to sup- 
port regionalization such as regional 
educational coordinators and we're 
now looking at regional ambulatory 
care coordinators. We have also put 
more emphasis and more billets into 
the outpatient area. 

One of our most important areas 
for emphasis is career development 
for our senior nurses within the 

clinical areas. A nurse may now re- 
main in ambulatory care, a clinical 
specialty, or in education and still 
have an opportunity for promotion 
to captain. This was not true in the 
past. They all had to go into admin- 
istration. With regionalization and 
the broader scope for nursing ser- 
vice, we have been able to identify 
certain jobs that require that rank 
within the clinical fields. I firmly 
believe that the Director of Nursing 
Service position should be regional- 
ized to provide the authority to 
move more freely within the region. 

We're hearing more about physi- 
cian's assistant programs and inde- 
pendent duty corpsmen talcing on 
additional responsibilities in the 
health care field. What role do you 
see nurses playing in this new 

In the health care field it is recog- 
nized that people are demanding to 
be kept well rather than waiting to 
be made well. Health teaching is, 
therefore, very important. I am con- 
vinced and will tell everyone that 
our nurses are probably the best 

U.S. Navy Medicine 

teachers of any in the health field. 
Whereas our physician's assistants 
— and I think there is a great need 
for them — are very much disease 
oriented as are our physicians; our 
nurses are more directed toward 
health maintenance and health edu- 
cation. I see a tremendous need for 
health teaching such as in nutrition, 
especially for our young people in 
the Navy. Nurses are going to be- 
come even more involved in teach- 
ing the patient. 

What incentives are being offered 
to recruit new nurses? 

The Nurse Corps has always been 
an all volunteer corps. For 60 or so 
years we were an all female corps. 
During those years, we established 
our civilian recruiting contacts. We 
are not going through the same tur- 
moil that the other corps are experi- 
encing in recruiting. Educational 
opportunity is probably the number 
one reason given by a nurse who 
chooses the Nurse Corps. The op- 

grams in education that weren't 
there before? 

In overall numbers, our training 
billets have stayed about the same. 
Certain programs have changed. 
When I assumed this job our anes- 
thesia program was very healthy. 
We had many more nurse anesthe- 
tists than we had billets for. Be- 
cause of opportunities in the civilian 
community we've lost a number of 
our nurse anesthetists. We are 
therefore putting more emphasis 

We have been forced to view our areas 
for performance beyond the four walls 
of a hospital. 

I am convinced and will tell everyone 
that our nurses are probably the best 
teachers of any in the health field. 

My successor will have the opportunity 
to work with the other federal nursing 
chiefs . . . on many emerging issues of 
national interest. 

Back in '76 you said that retention 
was fairly stable. One problem of 
increasing concern has been the loss 
of trained professionals not just in 
the Navy but in the armed forces 
generally. We're losing doctors at 
an alarming rate. Are we losing 

Our retention rate has been very 
good. In '77 and '78 it was about 
60 percent for those completing 
their initial tour, which is extremely 
high for the Navy. I don't see a 
problem for the Nurse Corps at the 
present time. 

portunities we offered in the past 
for travel no longer seem to be the 
primary factor. 

What is the general quality of the 
new nurse coming into the Navy? 

The quality is outstanding. I am 
impressed and foresee rapid, pro- 
fessional advancement within the 
Nurse Corps. 

Have educational opportunities 
increased or changed over the past 
three years. Are there new pro- 

and people into our anesthesia pro- 
gram now than we did three years 

Three years ago we were opening 
up and pushing our practitioner pro- 
grams and now the numbers are 
climbing closer to our available 
billets all the time. 

Now certain regulatory bodies re- 
quire formal education in certain 
clinical specialties. They no longer 
consider on-the-job training suffi- 
cient to work in those specialty 
areas. This has required increased 
support for many short courses. 

Volume 70, May 1979 

In the health care field it is recognized that people are demanding to be kept well 
rather than waiting to be made well. 

In the past few years there has 
been increased automation and the 
introduction of higlily sophisticated 
equipment into naval medical facili- 
ties. Has this adversely affected the 
patient-nurse relationslilp? 

It has increased the demand for 
more nurses. As an example, we 
have opened more neonatal inten- 
sive care units and have found the 
requirement is one nurse for every 
infant around the clock. When we 
open a 15-bed neonatal ICU we 
need anywhere from 45 to 47 nurses 
just to man that one clinical area. 
Our surgical ICU's, our medical 
ICU's and our coronary care facili- 
ties require many personnel. The 
ratio of nurse to patient has climbed 

When we think of automation, we 
often see it in terms of an automo- 
bile assembly line. You install more 
equipment and you take more 
people out of the picture. In this 
case the mere sopliistication of the 

equipment requires more people. 

Yes. And it requires much more 
than two hands. It requires in-depth 
knowledge as well as the sophistica- 
tion of our equipment. 

What is the Nurse Corps Quality 
Assurance Program? 

We have to provide that the care 
we give the patient is effective and 
in his or her best interest. It must be 
measured and documented so that 
our training programs and proce- 
dures can be updated and im- 
proved. Now about 25 percent of the 
nurse's time is spent in documenta- 
tion or complying with regulatory 
requirements. It must be remem- 
bered that nurses are not the only 
participants in quality assurance. 
This has become such a large area 
as to require a Quality Assurance 
Office at BUMED. 

What has been done to update 
patient care planning systems? 

We reviewed many of the forms 
that we were using at the patient 
care level and found that some com- 
mands had generated many forms 
to fulfill the demands for increased 
documentation. One command 
found the need to generate 47 dif- 
ferent chits. We are trying to elimi- 
nate duplication wherever possible. 
A good example is the recording of 
a patient's vital signs. Vital signs 
are taken in the clinic or the emer- 
gency room, at the ward level, then 
taken again by the physician, and it 
goes on and on. We were duplicat- 
ing much of the initial care; now 
we're trying to streamline wherever 

What challenges do you see for 
your immediate successor? 

She will have a number of chal- 
lenges. I believe there may well be a 
national health insurance program 
during her tenure. I don't think any- 
one yet knows what impact this will 
have on military medicine. 

My successor will have the oppor- 
tunity to work with the other federal 
nursing chiefs — the Army, Air 
Force, Public Health Service, and 
the Veterans Administration on 
many emerging issues of national 

Other possibilities exist. We 
recently had four Nurse Corps offi- 
cers attend a course in cold weather 
training in the high mountains of 
Colorado, The opportunities for in- 
volvement in operational medicine 
are therefore becoming more com- 
mon. The whole issue of "Readi- 
ness" will require monitoring and 
creative efforts. 

There is tremendous talent, imag- 
ination, and drive within our nurs- 
ing services. Everywhere I go I'm 
seeing new areas that we nurses are 
becoming involved in. The chal- 
lenges for my successor and for 
Navy nurses in general are very ex- 

U.S. Navy Medicine 

Adverse Health Effects of Smoking and 
the Occupational Environment 

Medical Department personnel 
have long been aware of the health 
hazards associated with cigarette 
smoking and tobacco use. Less ap- 
parent, however, are the additional 
risks which attend smoking in spe- 
cific work environments. The most 
recent example in the Navy com- 
munity is the increased risk of lung 
cancer in workers who were exposed 
in the past to excessive concentra- 
tions of airborne asbestos fibers. 
The following is reproduced from 
American Occupational Medicine 
Association Report, March 1979: 

"NIOSH recommends that the 
use of and/or carrying of tobacco 
products into the workplace be cur- 
tailed in situations where employees 
may be exposed to physical or 
chemical substances which can in- 
teract with tobacco products and 
that there be simultaneous control 
of worker exposure to physical and 
chemical agents. Six ways in which 
smoking can act in combination with 
hazardous agents in the workplace 
to produce or increase the severity 
of a wide range of adverse health 
effects have been identified. It 
should be noted that the six mech- 
anisms are not mutually exclusive 
and several may prevail for any 
given agent. The six models of in- 
teraction follow: 

• Certain toxic agents in tobacco 
products and/or smoke may also 
occur in the workplace, thus in- 
creasing exposure to the agent. For 
example, cigarette smoking causes 

increased exposure to carbon mon- 
oxide (CO), A CO concentration of 
4% (40,000 ppm) in cigarette smoke 
can lead to a lung CO concentration 
of 0.04 to 0.05% (400 to 500 ppm), 
which can produce CO blood con- 
centrations, as measured by the 
carboxyhemoglobin (COHb) level, 
of 3 to 10%, 

• Workplace chemicals may be 
transformed into more harmful 
agents by smoking. Investigations 
of outbreaks of polymer fume fever 
provide a clear illustration of this 
effect. Other examples include a 
number of chlorinated hydrocarbons 
that have the potential for conver- 
sion to phosgene. 

• Tobacco products may serve as 
vectors by becoming contaminated 
with toxic agents found in the work- 
place, thus facilitating entry of the 
agent into the body by inhalation, 
ingestion, and/or skin absorption. 
The effects of smoking cigarettes 
contaminated in the workplace with 
known amounts of tetrafluoro- 
ethylene polymer have been studied 
with the assistance of human volun- 
teers. Nine out of ten subjects were 
reported to exhibit typical polymer 
fume fever symptoms after each 
had smoked just one cigarette con- 
taminated with 0.40 mg tetrafluoro- 
ethylene polymer. Among other 
potential contaminants of tobacco 
products are boron trifluoride, car- 
baryl, and lead. 

• Smoking may contribute to an 
effect comparable to that which can 
result from exposure to toxic agents 

found in the workplace, thus caus- 
ing an additive biological effect. For 
example, combined worker expo- 
sure to chlorine and cigarette smoke 
can cause a more damaging biologi- 
cal effect than exposure to chlorine 

• Smoking may act synergistical- 
ly with toxic agents found in the 
workplace to cause a much more 
profound effect than that antici- 
pated simply from the separate 
influences of the occupational ex- 
posure and smoking. Asbestos pro- 
vides one of the most dramatic ex- 
amples of severe health damage 
resulting from interaction between 
the smoking of tobacco products 
and workplace exposures. 

• Smoking may contribute to 
accidents in the workplace. In a 
nine-month study of job accidents, 
the total accident rate was more 
than twice as high among smokers 
as among nonsmokers. It has been 
suggested that injuries attributable 
to smoking were caused by loss of 
attention, preoccupation of the hand 
for smoking, irritation of the eyes, 
and cough," 

It should be noted that eating or 
snacking in the workplace also may 
be dangerous because food, as well 
as tobacco, may serve as a vector 
when it becomes contaminated with 
toxic agents. Hand-washing and a 
little hygienic common sense can go 
a long way in reducing unnecessary 
exposures to work hazards among 
our active duty personnel and civil- 
ian employees. 

Volume 70, May 1979 


BUMED Completes Reorganization 

Moving offices, changing codes, and coping with dis- 
ruption has never been popular in any organization. 
Most employees, when faced with such unpleasant 
prospects, are heard to exclaim, "Oh no, not another 
reorgan ization . " 

Well, reorganization is not a probability but an estab- 
lished fact at BUMED. Personnel and furniture have 
already been relocated, and an organizational manual 
and new telephone directory are soon to be released. 

The new reorganization was not initiated on whim 
but based instead on a conscious decision to streamline 
and make BUMED more responsive to the Navy's 
health care needs. 

In early 1978 the Surgeon General, with the support 
of the Assistant Secretary of the Navy for Manpower, 
Reserve Affairs, and Logistics, commissioned a study 
by an independent management consultant organiza- 
tion. The consultants analyzed all aspects of BUMED 's 
operation — mission, goals, management philosophy, 
operating strategy, techniques, and controls. Although 
they identified many strengths, most notably in analyti- 
cal, planning, and programming capability, they also 
found several deficiencies: 

• BUMED frequently engaged in crisis manage- 
ment, reacting to situations rather than anticipating 
and planning for them. 

• The Bureau's energies were frequently devoted to 
relatively routine internal administrative tasks. 

• BUMED found it difficult to achieve internal co- 
ordination on matters ranging from routine administra- 
tion to fundamental policy issues. 

• Within BUMED and below the Surgeon General 
level, it was difficult to determine responsibility and 
accountability for support of BUMED programs. 

Other problems existed, the key one being a diffusion 
or fragmentation of management responsibilities. Only 
the Surgeon General had the authority to rule on a 
broad spectrum of individual issues. Some delegation 
of authority existed but not enough to free the Surgeon 
General from many routine administrative decisions 
and allow him to concentrate on important policy 
matters. His involvement in almost every aspect of 
management resulted in the proliferation of numerous 
committees and special assistants. 

In short, the study found the Bureau's operation to 
be topheavy, outdated, and inefficient, I 


The Surgeon General's new role is specifically de- 
fined. He can now focus his attention on the resolution 
of major policy issues and have more time to maintain 
contacts with higher authority. 

The Chief of Staff supervises a streamlined and effec- 
tive staff. 

The Deputy Surgeon General is delegated a more ex- 
tensive role in the day-to-day direction of the head- 
quarters operation. 

The five existing codes have been consolidated into 
three major organizational units with defined responsi- 
bilities for planning, resource acquisition, professional 
development, and health care programs. 

Well defined channels of communication have been 
established below the Surgeon General level. There are 
also definite points of contact for BUMED-managed 

Organizational Charts 

The Surgeon General is supported by five key posi- 
tions — the Deputy, a Chief of Staff, an Executive As- 
sistant, the Inspector General, the Master Chief Petty 
Officer of the Force, and the Special Assistant for 
Research and Development. 

The Chief of Staff is a special advisor and assistant to 
the Surgeon General, coordinating all activities of the 
special assistants. 

The Executive Assistant continues to handle adminis- 
tration and coordination of the Office of the Surgeon 

The Deputy Surgeon General takes on responsibili- 
ties for day-to-day internal management of the head- 
quarters operation. The Assistant Chiefs and Director 
of Headquarters Services report through the Deputy to 
the Surgeon General. The Dental Division and the 
Headquarters Services Division change only slightly. 
Organizationally, the three main Divisions change sig- 

Assistant Chief for Planning and Resources. This 
organization has five distinct organizational elements: 

• Contingency Planning Division 

• Resource Planning and Analysis Division 

• Management Information Division 

• Program/Budget Division; and 

• Resource Execution Division 


U.S. Navy Medicine 





MED 00 


MED 001 



MED 003 

MED 004 




MED 09 

MED 01 

MED 02 

MED 04 


MED 03 


MED 5 





MED 11 


HED 12 





MED 13 


MED 14 


MED 15 





[^ MED-22 I 


MED- 2 3 [ 


HED-22 I MED-24 











Volume 70, May 1979 












MED- 311 


MED- 31 3 

MED- 31 2 






MED- 32 1 


MED- 322 

In addition, the Assistant Chief for Planning and Re- 
sources is aided by special assistants for manpower and 

Assistant Chief for Professional Development. This 
organization is responsible for the recruitment, profes- 
sional development, and retention of personnel, as well 
as the development of professional standards and 
standards of care. 

In addition to the five corps divisions, there are the 
Physical Standards Division and the new Quality 
Assurance Division. 

The Assistant Chief for Professional Development is 
also assisted by a Special Assistant for Education and 
Training — the Commanding Officer, Health Sciences 
Education and Training Command, and a Special As- 
sistant for Naval Reserve. 

The Dental Corps is represented through a collateral 
or additional duty assignment. 

The Corps Division take a leading role in the develop- 
ment of professional standards and programs designed 
to increase the quality of services delivered. In this 
regard, the Corps Divisions review the qualifications, 
mix, and use of personnel. 

The Quality Assurance Division is responsible for 
developing standards for health care delivery and for 
monitoring care delivery. 

Assistant Chief for Health Care Programs. This office 
directs all operational and clinical medicine programs. 
It consolidates program njanagement activities and 
permits integrated review and management of the re- 
source mix. It provides support and direction to 
BUMED-managed activities. The Assistant Chief for 
Health Care Programs is the Program Manager and 
advocate for the field within BUMED. 

The organization is divided into three basic elements. 
The Director, Program Operations, coordinates support 
and monitors the health care delivery mechanism. The 
Regional Operations Division is the day-to-day link with 
all BUMED-managed activities. 

The Director, Program Support, identifies program 
requirements for facilities, equipment, and logistics. 

The above charts should serve to illustrate the new 
BUMED organizational structure. What should be 
evident is its relative simplicity. It is hoped that re- 
organization will solve many of the old problems and 
bring a high level of efficiency to the Navy's entire 
health care system. 

Volume 70, May 1979 














MED 040 


OfliM of the Chief MED-Mi) 
Deputy Chief MF-D-WB 


















_l __ 



MED -41 




1 - 





MED -431 





MED -412 


1_ ., 1 








■f " ■ " ■ 

























Organization and Reorganization of BUMED 


BUMED established by act of Congress 

• Special Assistants for Automated Data 
Processing, Education and Training, 


Office of the Surgeon General becomes a 

and Medical Research and Develop- 

full-time position 

• Corps Directorate 


BUMED reestablished into six components: 

• Surgeon General and Chief of the 

The essential elements of the present BU- 


MED Headquarters structure were created: 

• Deputy Surgeon General and Assistant 

• The Operational Medical Support orga- 

Chief of the Bureau 

nization grew out of the Aviation Medi- 

• Assistant Chief for Professional and 

cine and Medical Specialties functions 

Personnel Operations 

• Planning and Logistics became the Of- 

• Assistant Chief for Planning and Logis- 

fice of Program Planning and Analysis 


and a separate Materiel Resources Or- 

• Assistant Chief for Dentistry 


• Assistant Chief for Aviation Medicine 

• Establishment of a Regional Health 

and Medical Military Specialties; in 

Care Administration 

1947 this was changed to the Assistant 

Chief for Aviation and Operational 

Medicine and Assistant Chief for Re- 

1977 An internal study proposed major changes 

search and Military Medical Specialties 

in this organization framework; study was 
not implemented 


BUMED reorganization and addition of: 

• Naval Medical Research and Develop- 

1978 independent study commissioned by private 

ment Command and Health Sciences 

consultant and findings implemented 16 

Education and Training Command 

April 1979 

Volume 70, May 1979 



Asbestos-Related Diseases 

CDR Joseph J. Bellanca, MC, USN 

Asbestos is a fibrous insulation material used to 
control the escape of lieat from ship's broiler and steam 
pipe systems. When airborne asbestos fibers are in- 
haled in significant amounts, serious diseases and 
death may result. These diseases, asbestosis and can- 
cer, often do not become apparent for 20 or more years 
after the beginning exposure. Protective measures de- 
signed to keep down the risk of asbestos exposure in 
the Navy include: dust control, use of respiratory pro- 
tective equipment, a medical surveillance program of 
personnel potentially exposed to asbestos. 

Asbestosis is a gradual fibrosis of the lungs which 
causes shortness of breath and eventually heart failure. 
It occurs in workers with heavy exposure to airborne 
asbestos dust. Most asbestosis now seen in workers 
began with heavy exposure 10 or more years ago. 

Early asbestosis is identified on chest X-rays as in- 
creased interstitial densities which are most evident in 
the lower lung zone. Small irregular and linear 
opacities may appear as the disease progresses. The 
cardiac and diaphragmatic outlines become less sharply 

Pleural changes are an early sign of asbestos expo- 
sure and are not associated with symptoms or disabil- 
ity. Pleural plaques, sometimes calcified, may be seen 
on the chest X-ray as distinct nodular densities at the 
edge of the lung fields. Pleural thickening appears as 
decreased sharpness between the lung and the inner 
chest wall, usually located in the lower and middle por- 
tions of the lungs bilaterally. When calcified, they have 
a bizarre holly-leaf or lace-like appearance. 

Pulmonary carcinoma is an important problem in 
former workers who have had heavy asbestos exposure 
and who smoke. Studies of heavily exposed workers in- 
dicate that lung cancer incidence increases with the 
degree of asbestosis. Nonsmoking asbestos workers do 

From the Department of the Navy, Bureau of Medicine and Sur- 
gery (Code 3142). Washington, D.C. 20372. 

not appear to be at increased risk of pulmonary car- 
cinoma. Asbestos-related lung carcinoma is similar to 
other lung carcinoma. Symptoms include cough, chest 
pain, hemoptysis, and weight loss. The diagnosis is 
confirmed by chest X-ray or other usual diagnostic 

Mesothelioma is a rapidly fatal malignant cancer of 
the lining of the chest or the peritoneal cavity. In the 
chest, the first symptoms are usually pain and progres- 
sive shortness of breath. Chest X-rays show pleural 
effusion, irregular pleural thickening, or mass shad- 
ows. Peritoneal mesothelioma causes pain, weight loss, 
and ascites. Mesothelioma is rarely curable when dis- 

In managing workers with exposure to airborne 
asbestos, certain points should be emphasized: 

• Occupational exposure history. A detailed lifetime 
history should be obtained. This is time consuming but 
important because significant exposures may have 
been brief and have occurred years ago, 

• Clinical findings. A detailed history for symptoms 
of shortness of breath on exertion, chest X-rays, and 
pulmonary function tests are important for early diag- 
nosis. Early X-ray changes are subtle; X-rays must be 
reviewed carefully by experienced "B" readers who 
have been trained to interpret X-rays for pulmonary 
dust disease. Such readings should include a thorough 
search for pleural changes, the earliest sign of asbestos 

• Emphasis on preventive measures. Large multi- 
center studies sponsored by the National Cancer Insti- 
tute show that early detection of lung cancer by present 
medical screening techniques is not effective in reduc- 
ing mortality due to lung cancer. Therefore, the most 
effective measures for the prevention of all asbestos- 
related diseases are cessation of cigarette smoking and 
avoidance of exposure to airborne asbestos. Cessation 
of smoking significantly diminishes the risk of lung 
cancer in workers exposed to asbestos. 

Since smoking is a deeply ingrained habit, dire 


U.S. Navy Medicine 


Chest film exhibiting advanced asbestosis with fine irregular 
opacities in all lung zones, particularly in the lower zones. 
The cardiac outlined is ill-defined. 

warnings about the danger are rarely helpful. Few 
people appreciate an intellectualized scolding lecture, 
and studies have been demonstrated that the "scare" 
approach is ineffective. In fact, the smoker's everyday 
experience contradicts the statistical evidence about 
the dangers of smoking. Most people recognize that the 
great majority of smokers do not die of lung cancer or 
other diseases at a noticeably early age. Statistics may 
not be "significant" to the individual. 

Although there are no absolute laws of human be- 
havior, a friendly encouraging approach is often help- 
ful. Support plus "how to" suggestions lead to suc- 
cessful interventions. Handouts available from volun- 
tary health organizations provide a wide variety of 
useful techniques. 

Current Navy policy concerning asbestos exposure is 
defined in OPNAV 6260.1 A. Medical personnel should 
emphasize the importance of proper asbestos work pro- 
cedures and the use of respiratory protection. The risk 
of asbestos exposure in the workplace can be minimized 
if each Medical Department representative contributes 
enthusiastically to the effort. 

Autopsied lung encapsulated and compressed by a thick malignant mesothelioma 
Volume 70, May X979 



Roentgenographic Findings of 
Asbestos Exposure 

CAPT John P. Smith, MC, USN 
CAPT Charles W. Ochs, MC, USN (Ret. 

The hazards of asbestos have recently been brought 
to public attention by the press and television. The 
Navy has particularly been subject to criticism for its 
previous widespread use of this substance and for fail- 
ing to detect its effects in military personnel and ship- 
yard workers. Early changes of asbestos exposure 
usually cannot be detected by physical examination or 
pulmonary function tests. However, there are certain 
findings in routine chest radiography which may indi- 
cate this exposure. These are reviewed in the following 


Proper radiographic technique for the detection of 
asbestos-related change requires optimal visualization 
of both the pleura and the interstitial lung markings, In 
general, a high kV, wide latitude .technique which 
allows faint visualization of the first five or six thoracic 
vertebrae behind the heart is ideal. This allows a toler- 
ance for error and produces consistent film quality with 
less radiation to the patient. The kV should be in the 
range of 120 to 140, with an exposure time of 1/30 
second or less. Three-phase equipment is preferred. 

Film and screen speed vary with size of the grain or 
crystal. An inverse relationship holds for resolution. As 
motion also degrades the quality of the image, a com- 
promise between resolution and speed must be made. 
Medium (par) speed film and screen combinations 

CAPT Smith is chatrman, Department of Radiology, National Naval 
Medical Center, Bethesda. Md. 20014. 

Dr. Ochs is chairman, Department of Radiology, Cooper Green 
Hospital, Birmingham, Ala. 35233. 

produce the most satisfactory results. The increased 
scatter radiation produced by the high kV technique 
requires a high resolution 103 line per inch, 10:1 fixed 
grid focused at 72 inches. Alternatively, an air gap 
technique may be employed, (i) 

The radiograph must be taken in full inspiration. 
Expiration will falsely increase interstitial markings. 
The top of the diaphragm must be at least at the level of 
the sixth anterior or ninth posterior ribs. A 1.2 mm or 
less tube focal spot is mandatory for a sharp image. 

Normally, only an erect PA view is needed. As the 
pleural changes of asbestos exposure usually first occur 
in the posterolateral pleura, oblique views may be used 
in equivocal cases to show this area in profile. 

TABLE 1. Characteristics of 
Asbestos-Related Pleural Thickening 


1. Mid-thoracic region of the lateral parietal pleura 
with anterior and posterior extension. 

2. Spares apex, costophrenic angle. 

3. Bilateral; flat or nodular masses (plaques). En face, 
vague haziness. 

4. Slowly progressive; years to detect change. 

5. Calcification, late. 

6. Rjlmonary fibrosis uncommon. 

7. Asymptomatic. Pulmonary function usually 
mild compliance loss. 



U.S. Navy Medicine 

- o 

FIGURE 1. Films in inspiration and expiration. The encircled 
calcifications demonstrate that maximum excursion between 
the pleural surfaces occurs at the mid-thoracic region. 


Extensive roentgenographic and autopsy studies on 
British shipyard workers (2) and the general population 
of London and Copenhagen (3, 4) suggest that only 10 to 
15% of the pleural plaques present at autopsy are seen 
radiographically.(5) While pulmonary parenchymal 
asbestosis is relatively uncommon in active duty or 
retired Navy personnel, pleural thickening or plaques 
are seen roentgenographically in about 5% of those 
over age 50.(6) Both changes progress slowly; three 
years is usually needed before a significant increase 
can be detected. 

Typically, a 15- to 20-year latent period exists be- 
tween the initial exposure and appearance of radio- 
graphic findings. Pleural plaques may be the result of a 
single short-term exposure many years in the past.(7) 

Radiographic Findings 

Pleural Plaques. Pleural plaques are a hallmark of 
asbestos exposure. They are the most common asbestos 
related findings in Navy personnel and shipyard 
workers (Table 1). While they can be produced by mica, 
fiberglass, carborundum, graphite, aluminum silicate, 
and diatomaceous earth, asbestos is by far the most 
common cause. (6, 5) 

The normal pleura above the level of the fourth rib 
can be up to 5 mm thick on the PA view and up to 10 
mm thick on the oblique view. Below the fourth rib it 
should be a thin line less than 1 mm. (5) Pleural plaques 

Volume 70, May 1979 

due to asbestos are most commonly seen on the 
posterior lateral aspect of the chest wall between ribs 
five and nine, (6) as this is where the excursions be- 
tween the parietal and visceral pleura are greater 
(Figure 1). The plaques are located exclusively on the 
parietal pleura, are sharply marginated and irregular. 
Microscopically, they consist of subpleural dense 
hyaline connective tissue. It is postulated that inhaled 
fibers migrate through the visceral pleura and irritate 
the parietal pleura during respiration. (6) 

A confluence of plaques is responsible for the roent- 
genographic pleural change. Early there is a slight 
thickening of the pleural stripe adjacent to a rib. The rib 
is thus separated from the lung by a small area of water 
density (Figure 2). Later the plaques become oval with 
tapering superior and inferior margins characteristic of 
an extrapleural lesion (8) (Figures 3 and 4). Plaques on 
the chest wall are usually seen radiographically before 
those on the diaphragm; however, diaphragmatic calci- 
fications are easier to identify. En face this thickening 
appears as a vague haziness and oblique tangential 
views are needed to demonstrate the pleural origin. 
Calcification occurs 20-30 years after exposure and 
produces a dense dot-dash or continuous line when 
seen in profile. En face, sharply angular lines of calcifi- 
cation appear. 

Pleural thickening is a reliable sign of asbestos ex- 
posure only if bilateral with sparing of the apices and 
costophrenic angles. Otherwise, the finding becomes 


FIGURE 2. Early plaque formation. The fifth-ninth ribs are 
separated from the air-filled lung by a smalt area of water 


FIGURE 3. Spectrum of plaque formation from normal to extensive. Note the tapering margins of an extrapleural lesion as the 
thickness increases. 

nonspecific and is likely the result of previous trauma or 
inflammation. (<S) 

Diffuse Pleural Thickening. This is considerably less 
frequent than plaque formation. It is initially seen in 
the basilar regions where it presents as an ill-defined 
diaphragm. Later, pericardial adhesions, thickened 
interlobar septa, and occasionally thickening of the 
entire pleural surface occur.(9, 7C) Unlike pleural 
plaques, this may be associated with pulmonary func- 
tion abnormalities. (U) 

Pleural Effusion. Most pleural effusions seen in the 
course of asbestosis are related to underlying malig- 
nancy. (9) Benign pleural effusion is a relatively rare but 
distinct entity which is being reported with increasing 
frequency. The effusion is an exudate and interstitial 
fibrosis is present in the underlying lung. It may be 
unilateral or bilateral, undergo spontaneous resolution, 
or progress to diffuse pleural thickening.{/0) The diag- 
nosis should be entertained only after mesothelioma, 
other malignancy, and TB have been excluded. 

The parenchymal lung change of asbestos exposure 
is interstitial fibrosis, predominantly in the basilar 
areas. In the ILO U/C classification this is the small 
irregular (s, t, u) opacity, Kerly B lines may be seen 
and progression to the honeycomb lung may occur.(/2) 
About half will also have pleural changes. (70) 

Interstitial lung disease is also nonspecific and diffi- 
cult to diagnose by radiographic means in the early 
stages. Slight variations in radiographic technique can 
obscure or give false positive findings. Detection of 

FIGURE 4. Extensive bilateral plaque formation. The costo- 
phrenic angles and apices are spared. The vague haziness 
over the lower lung fields is caused by en face plaques. 

minimal disease is often subjective; however, the 
presence of Kerly B lines are an objective finding 
indicative of an abnormality in the lung interstitium. 
Other objective criteria have been suggested based 
upon the appearance of perivascular fibrosis. These in- 
clude increased visibility of normal lung markings, 


U.S. Navy Medicine 

thickening of small vessels at points of branching, visi- 
bility of vessels to the pleural surface, and nodularity 
along these vessels.{9) 

The pulmonary parenchymal changes of asbestosis 
may progress in spite of the removal of exposure. There 
is evidence that an autoimmune process causes pro- 
gression after initiation by the asbestos fibers. (i2) 

Discussion and Summary 

Low level exposure to asbestos, such as Navy person- 
nel are likely to encounter, produces pleural change 
earlier and more frequently than parenchymal change. 
The term "asbestosis" should be reserved for paren- 
chymal lung disease. The appearance of bilateral 
pleural thickening with sparing of the apices and costo- 
phrenic angles should alert one to the possibility of 
previous asbestos exposure. While pleural plaques 
alone are not associated with significant pulmonary 
function abnormalities, the asbestos exposure they 
indicate may put the patient at higher risk for the de- 
velopment of lung carcinoma or mesothelioma. It is 
known that asbestos is a strong potentiator of cigarette 
smoking in the production of bronchogenic carcinoma. 
These personnel, therefore, should stop smoking. 

In summary, pleural plaque formation is the most 
frequent change likely to be encountered in Navy 
personnel and should alert the physician to the possi- 
bility of previous asbestos exposure. 


1. Sargent EN: A Home Study Syllabus on Technics for Chest 
Radiography. American College of Radiology, pp 5-12, 1973. 

2. Harries PG, MacKenzie FAF, Sheers G, Kemp JH, Oliver TP, 
Wright DS; Radiologic Survey of Men Exposed to Asbestos in Naval 
Dockyards. Brit J Indmtr Med I'i-.Tl'^-n^, 1972. 

3. Hourihane D, Lessof L, Richardson PC: Hyaline and Calcified 
Pleural Plaques as an Index of Exposure to Asbestos. Features of 100 
Cases with a Consideration of Epidemiology. Brit Med J 1:1069-1074, 
April 30. 1966. 

4. Francis D, Jussuf T, Mortensen B, Sikjer B, Viskum K: 
Hyaline Pleural Plaques and Asbestos Bodies in 198 Randomized 
Autopsies. Scan J Resp Dis 58:193-196, 1977. 

5. Thompson JG: Pathogenesis of Pleural Plaques. International 
Conference on Pneumoconiosis, Johannesburg, April 23-May 2, 

6. Ochs CW, Smith JP: Chronic Pleural Thickening: Some Ob- 
servations on Cause and Pathogenesis. Milit Med 141:77-81, Feb 

7. Kiviluoto R: Pleural Plaques and Asbestos: Further Observa- 
tions on Endemic and Other Non-Occupational Asbestosis. Ann NY 
Acad Sci 132:235-239, 1966. 

8. Sargent EN, Jacobson G, Gordonson JS: Pleural Plaques: A 
Signpost of Asbestos Dust Inhalation. Seminars in Roentgenology, 
XlI(4):287-297, Oct 1977. 

9. Fletcher DE, Edge JR: The Early Radiological Changes in 
Pulmonary and Pleural Asbestosis. Clin Rod 21:355-365, 1970. 

10. Becklake MR: Asbestos Related Diseases of the Lung and 
Other Organs: Their Epidemiology and Implications for Clinical 
Practice. Am Rev Resp Dis 114:187-227, 1976. 

11. lumley KP: Physiological Changes in Asbestos Pleural Dis- 
ease. Inhaled Part 4 Pt. 2:781-788, Sept 1975. 

12. Turner-Warwick M: A Perspective View on Widespread Pul- 
monary Fibrosis. Brit Med J 2:21l-21t, May 18, 1974. 


WIC Program in Operation 

The purpose of the WIC 
(Women, Infants and Children's 
Special Supplemental Food Pro- 
gram) as stated in the Child 
Nutrition Act of 1975 (Public Law 
94-105) is "... to provide sup- 
plemental nutritious foods as an 
adjunct to good health care 
during such critical times of 
growth and development in order 
to prevent the occurrence of 
health problems." 

In conjunction with the State of 
North Carolina and the Craven 
County Health Department, a 
WIC office was established at the 
Naval Hospital, Cherry Point, in 
Match 1979. The WIC program 
has authorized a case load of 500 

patients to be followed jointly by 
the naval hospital staff and the 
WIC nutritionist assigned to the 
hospital. Generally, the WIC pro- 
gram is aimed at prevention of 
health problems by improving 
pregnancy outcome and by at- 
taining satisfactory growth and 
development of infants (birth to 1 
year of age) and children (1 year 
to 5 years of age) through im- 
proved nutrition. 

The program involves screen- 
ing and referral of patients with 
nutritional risk to the WIC nutri- 
tionist for evaluation against the 
program's certification criteria. 
If eligible within the WIC guide- 
lines, the patient is provided 

nutritionally supplemental foods 
through the WIC funding proc- 
ess. The patient is evaluated 
each month by the WIC nutri- 
tionist who also provides nutri- 
tional counseling. At the end of 
six months a determination is 
made to continue or discontinue 
in the WIC program based on the 
nutritional risk still involved. 

The WIC program at Naval 
Hospital, Cherry Point, is inte- 
grated with all services, but 
mainly with family practice, 
pediatrics, and obstetrics/gyne- 
cology. Additional information 
about the program is available 
from the CO, Naval Hospital, 
Cherry Point, N,C. 28533. 

Volume 70, May 1979 


Sampling for Airborne Asbestos Fibers 

LTJG Kenneth R. Still, MSC, USNR 
Roger R. Beckett 

Asbestos is a generic name applied to a number of 
naturally occurring mineral silicates differing in chemi- 
cal composition. Although there are numerous types of 
asbestos minerals, chrysotile, a hydrated magnesium 
silicate, is the most widely used, comprising approxi- 
mately 95% of the world asbestos production. (i, 6) 
Chrysotile, along with quantities of amosite, was in- 
stalled for many years on Navy ships and in shore activ- 
ities, (i) Commercially, there are approximately 3,000 
different products containing asbestos; however, major 
uses are in bonded products (building siding, water 
pipe, brake and clutch linings), fireproofmg materials 
(asbestos board), high temperature insulation, asbestos 
cloth, gasket materials, vinyl asbestos flooring, and 
others. (2) Current research is producing numerous 
asbestos-free substitutes, many of which are being 
utilized in modern day Navy ships. However, older 
vessels often contain original asbestos insulation which 
releases airborne fibers during removal. (1,3,4) Other 
tasks which can generate asbestos dust include power 
sawing of asbestos-containing fire retardant material, 
and brake relining and repair. These operations can 
generate concentrations of airborne asbestos which 
exceed permissible safe limits for personnel not prop- 
erly protected. 

The current Occupational Safety and Health Admin- 
istration Time Weighted Average for asbestos exposure 
is 2.0 fibers longer than five micrometers per cubic 
centimeter of air. (5) This value is the maximum 8-hour 
airborne concentration of asbestos fibers to which un- 
protected personnel may be exposed. Proposed 
changes to OPNAVINST 6260.1 may lower exposure 
standards to 0.5 fibers longer than five micrometers per 
cubic centimeter of air. The ceiling limit for exposure is 
not to exceed 10 fibers longer than five micrometers per 
cubic centimeter of air, at any time. Inhalation of exces- 
sive quantities of asbestos fibers over a prolonged 
period of time may produce several documented health 
hazards, notably asbestosis, bronchogenic carcinoma, 

LTJG Still is an industrial hygienist. Mr. Beckett is head of the 
Industrial Hygiene Branch, Occupational Environmental Health Ser- 
vice, NRMC Bremerton, Wash. 98314. 

and malignant mesothelioma of the pleura and perito- 
neum. (2, J, '^, 7) Because of the potential imminent 
health hazards associated with elevated asbestos fiber 
concentrations, a sound, functional sampling program 
of jobs involving asbestos-containing materials must be 
undertaken before, during, and after job completion. 

Sampling Strategy 

Sampling programs are designed and implemented 
for a variety of reasons. A major function of the indus- 
trial hygienist is to recognize, evaluate, and control 
health hazards in the industrial environment which may 
potentially affect the health of work force personnel. 
Environmental and personal sampling is one way to 
detect and evaluate potential workplace hazards. The 
major purpose for establishing a sampling program is 
to determine the level of worker exposure to occupa- 
tional hazards so that, if necessary, health protective 
measures can be instituted. There are, however, sever- 
al corollary reasons for sampling: determination of ex- 
posure for new processes or changes in established 
processes; determination of exposure resulting from a 
change in material usage; testing the effectiveness of 
installed engineering controls; research purposes for 
sundry reasons; and, determination for justification of 
worker grievances regarding potentially hazardous 
material exposure. 

Superficially, the concept of sampling appears to be 
quite simple. However, delicate details of a good sam- 
pling and/or monitoring program may be misunder- 
stood unless the person undertaking the work is ade- 
quately trained and under the direct technical supervi- 
sion of a professional industrial hygienist. Without 
guidance from an industrial hygienist, erroneous appli- 
cation of techniques, techniques lacking quality control, 
unawareness of malfunctioning instruments, improper 
usage of instruments, and data misinterpretation are 
common. Proper selection of a suitable sampling sub- 
ject and techniques which yield reproducible results are 
major problems encountered in establishing a sampling 
program. These problem areas can be overcome by 
meticulous planning prior to undertaking any sampling 
program. The basic framework for a good airborne 


U.S. Navy Medicine 

FIGURE I. Asbestos-containing insulation being removed from a section of pipe. This is one example of a job where air sam- 
ples should be collected before, during, and after the job. 

asbestos fiber sampling program is knowing what, 
when, where, and how to sample for airborne asbestos 

Sampling must be conducted on any job where air- 
borne asbestos fiibers are released. Only then can ade- 
quate control procedures be established and imple- 
mented. After such controls have been implemented 
additional sampling is superfluous, unless there are 
changes in the process, techniques, or material usage. 
If any changes occur, then new control procedures must 
be established based on additional data from a new 
sampling series. Once airborne fiber concentrations are 
lowered and brought to a permissible exposure level, 
further sampling is unwarranted, either on a financial 
or temporal basis. Sampling for numbers alone is not 

compatible with an effective asbestos sampling pro- 

Figure 1 is an example of a work process that must be 
sampled to determine appropriate engineering controls 
and personal protective equipment and monitoring. 
Asbestos insulation rip-out aboard ships and in shore 
facilities must be sampled and monitored closely be- 
cause of the confined spaces in which asbestos-contain- 
ing materia] can be found. Other examples of jobs that 
must be sampled, include installation/removal of 
asbestos-containing flooring, brake linings, gaskets, 
and packing. 

If a job involves a material that is suspected of con- 
taining asbestos, bulk samples of the material should 
be collected for fiber identification by an industrial 

Volume 70, May 1979 


hygienist. Before initiating a sampling survey pf the 
job, positive fiber identification is necessary to avoid 
wasted time, money, and manpower. 

An effective sampling program must be designed for 
accuracy and reliability. If this is accomplished, realis- 
tic spatiotemporal data will be obtained indicating fiber 
concentrations for that sampling period. Airborne fiber 
concentrations will vary for a variety of reasons, includ- 
ing worker mobility, changes in work practice, job 
processes, and air currents in the work space. (2) The 
amount of airborne dust present will also vary with 
environmental factors such as seasonality and various 
climatic factors. (2) Consequently, to adequately sample 
a worker's exposure to airborne fibers, sampling must 
be conducted on different days, under different 
weather conditions, during different seasons, during 
changes in worker production rate or routine, and peri- 
odically throughout the worker's entire work shift. 
Additionally, a background fiber concentration should 
be determined in the work space prior to commencing a 
job. Exposure is the ambient concentration, averaged 
over a specified time period, that a worker receives 
during his work shift. This is defined as the Time 
Weighted Average (TWA) exposure. The current TWA 
for airborne asbestos fibers is 2.0 fibers greater than 
five micrometers in length per cubic centimeter of air; 
this is the exposure level allowed for an 8-hour work 
period, and a 40-hour work week. Consequently, a 
sufficient number of samples need to be collected to 
determine the TWA throughout a complete job process. 

An asbestos sampling program used to devise control 
procedures must involve collection of samples in a 
number of locations, especially the breathing zone area 
of the individual worker. (2) Areas adjacent to the work 
site, directly at the work site, and spaces adjacent to the 
work site need to be initially sampled to institute ade- 
quate control procedures. To obtain representative 
samples of respirable asbestos dust, sampling appara- 
tus must be positioned near the worker's nose and 
mouth. Samples collected in the "breathing zone" 
represent dust which is likely to enter the worker's res- 
piratory system. 

Samples must also be collected in adjacent spaces to 
the work site and at the work site itself. These samples 
help in determining the amount of airborne fibers that 
occasional visitors or helpers might be exposed to while 
the job is in progress. From this information, safe 
boundaries can be established to limit the number of 
exposed personnel. Samples collected in these areas 
should also be obtained in the breathing zone. 

Sampling Procedure 

Airborne asbestos fibers are collected by using a 
sampling cassette and a battery operated vacuum 
pump. (2) The sampling cassette consists of the follow- 
ing pieces, in order from top to bottom: inlet plug, cap, 
two middle retaining rings, 37 mm diameter 0.8 mi- 
crometer pore size filter, filter pad, base, and outlet 
plug. Figure 2 shows the disassembled cassette with 
the filter and pad in the base; Figure 3 shows the 

FIGURE 2. Airborne asbestos fiber sampling cassette. From left to right is the cap with inlet plug, the two center retaining 
rings, and the base containing filter, filter pad, and outlet plug_ 


U.S. Navy Medicine 

cassette assembled and attached to the sampling 

The sampling pump is a light-weight, battery-oper- 
ated vacuum pump which can easily be worn by a 
worker. This type of pump allows collection of air 
samples on a long-term basis in the worker's breathing 
zone without interfering with the work process. Prior 
to use, the pump must be calibrated to determine an 
accurate air flow rate. The accuracy of the sample 
analysis is dependent upon the accuracy of the volume 
of air drawn into the pump. (2) All calibrations must be 
conducted to an accuracy of +5% for any flow rate 
between 1.0 and 2.5 liters per minute (Ipm), Figure 3 
shows one type of calibrator used for this purpose. It is 
important that the sampling pump be calibrated under 
the same conditions under which the sampler will be 
used in the field. (2) Pumps should be calibrated before 
and after each period of use. 

The cassette is attached to the sampling pump by a 
short piece of noncollapsible tubing, having an inside 
diameter of 1/4 inch. The tubing should be of sufficient 
length to reach from the worker's waist, across the 
shoulder, and attach to the shirt lapel. Two spring clips 
should be attached to the tubing so that it can be clip- 
ped to the worker's shirt lapel and one other location. 
The sampling pump is simply attached to the worker's 
belt. When the cassette is attached to the lapel it should 
be in the breathing zone and facing in a downward posi- 
tion to avoid falling debris gathering on the filter. With 
the cassette in this position the cap is removed to allow 
a more uniform distribution of collected fibers across 
the entire surface of the filter. The flow rate should be 
set at a minimum of 1.0 1pm to a maximum of 2.5 
1pm. (2) 

Acceptable asbestos sampling times range from 15 
minutes to 8 hours. (2) Duration for samples is depend- 
ent upon the following criteria: time weighted average, 
analytical method to be used, and suspected airborne 
concentration. If the sampling pump flow rate, TWA, 
and sensitivity of the analytical procedures are known, 
a minimum sampling time can be calculated prior to 
entering the work space. However, a preferable and 
recommended method is to sample the entire work 
process. (2) If the job process in question is of long 
duration, then the longer the sampling period, the more 
accurate and realistic the average concentration value. 
The fundamental reasoning for this procedure is that 
airborne fiber concentrations wUI vary with time and 
are dependent upon the operation. (2) In general, the 
short-term sampling period limitation should be a 
minimum of 15 minutes, but preferably 30 minutes, 
based on the number of fields to be counted and the 
number of fibers per field. (2) National Institute for Oc- 

FIGURE 3. Personal sampling pump with attached sampling 
cassette. Instrument in the background is one type of calibra- 
tor used to calibrate the personal sampling pump. Sampling 
pump with cassette as shown is ready for field use. 

cupational Safety and Health states: "As many fields as 
required to yield at least 100 fibers should be counted. 
In general the minimum number of fields should be 20 
and the maximum 100. "(2) Fiber counts follow a Pois- 
son distribution and these minimum values will yield a 
low variability of the count and greatly reduce the time 
spent counting the fibers. (2) 

Regardless of the length of the sampling period, 
replicate samples must be collected to determine a 
realistic estimated fiber exposure, whether the survey 
is for TWA concentrations or merely a job process ex- 
posure. The industrial hygienist must remember that 
the overall concern is the establishment of effective 
control procedures for worker health protection and not 
the collection of numbers for numbers sake. Consecu- 
tive samples collected over an entire work period prob- 
ably offer the "best" measurement because this strat- 
egy provides very narrow confidence limits. (5) How- 
ever, two consecutive samples collected for each four- 
hour period of the work shift will also insure sufficient 
accuracy and reduce additional overhead costs. If 
operational procedures make consecutive sampling dif- 

Volume 70, May 1979 


ficult to perform, samples may be collected at random 
short-term intervals for the operation. This time inter- 
val should cover the time period that the standard is 
based on. Sampling of this type is commonly termed 
grab sample measurement. (5) If the grab sample tech- 
nique is employed it is essential that 8 to 11 samples be 
collected to determine worker exposure, if exposure is 
relatively constant for the entire work shift. If exposure 
is not constant, 8 to 11 samples must be collected for 
each change in exposure concentration during the work 
shift. Sampling periods should be chosen entirely at 
random when the grab sample measurement technique 
is utilized. However, nonrandom selection is necessary 
if the exposure is to be compared with the ceiling 
value. (5) If exposure is to be compared with ceiling 
values, samples must be obtained during the period of 
maximum expected airborne concentrations. Samples 
collected for ceiling value comparison must be of a 15- 
minute duration, collected in the breathing zone, and 
triplicated for maximum usage. If three samples are 
collected for the work shift, error reduction is en- 
hanced; however, only the highest value would be sta- 
tistically tested. 
The utmost criterion for establishing an airborne 

asbestos fiber sampling program is worker health pro- 
tection. A valid, accurate, and realistic sampling pro- 
gram can be established by knowing what, when, 
where, and how to sample for airborne fibers. After 
controls have been instituted for a particular job, con- 
stant, continued sampling is unwarranted unless some 
aspect of the job has been altered. Occasional monitor- 
ing is sufficient to maintain up-to-date control proce- 


1. Marr WT; Asbestos Exposure During Naval Vessel Overhaul. 
Industrial Hygiene J 25:264-268, 1964. 

2. National Institute for Occupational Safety and Health: Criteria 
for a Recommended Standard . . . Occupational Exposure to Asbes- 
tos. NIOSH Pub No. 72-10267, 1972. 

J. Asbestos: A Clear and Present Danger. U.S. Navy Medicine 
69(6):8-10, June 1978. 

4. OPNAVINST 6260.1 of 9 April 1974; subj: Control of Asbestos 
Exposure to Naval Personnel and Environs. 

5. General Industry Standards, 29 CFR 1910 para 1001, 1976. 

6. SeWcoff U, et al: Asbestos Air Pollution. Arch Environ Health 
25:1-13, 1972. 

7. National Institute for Occupational Safety and Health: Revised 
Recommended Asbestos Standard. NIOSH Pub No. 77-169, 1976. 

8. Leidel NA, et al: Occupational Exposure Sampling Strategy 
Manual. NIOSH Pub No. 77-173, 1977. 

Reservists Donate 78 Units of Blood 

Concerned about cancer and 
sickness among children — offi- 
cers, sailors, and marines at the 
Denver Navy and Marine Corps 
Reserve Center, donated 78 units 
of blood to two Denver organiza- 
tions whose demand for blood is 

Thirty-five units of blood went 
to the American Cancer Society 
and 43 units of blood went to 
Children's Hospital. 

LT Kathy Noll, director of the 
program and member of 3rd 
Marine Air Wing, Detachment 
118, who implemented this dona- 
tion program, let it be known that 
the blood, collected during the 
annual drive, if not used by re- 
servists, families, or active duty 
personnel throughout the year, 
will be offered to worthy medical 

P03 Mary Walsh (left) gets her temperature taken electronically before giving 
blood. Karen Proett, lab technician, checks readout. 


U.S. Navy Medicine 



On 16 April a groundbreaking ceremony was held at 
Marine Corps Air-Ground Combat Center, Twenty nine 
Palms for construction of a single-story outpatient wing 
to be added to the existing Branch Hospital. The 3,498 
sq, ft. wing, to be completed by October 1979 at a cost 
of $459,292.00, will consist of 10 exam rooms, five 
doctors offices, an OB-GYN waiting room, and support- 
ing facilities. 


The University of Central Florida will initiate a pro- 
gram of behavioral modification for obesity to be spon- 
sored by the Naval Regional Medical Center, Orlando, 
Fla. in cooperation with the Nuclear Power School. The 
hospital staff will augment the program. 


Advanced Histology Techs (HM-8503) will train at 
AFIP, Walter Reed Army Medical Center beginning in 
October 1979. Navy personnel assigned to Basic Labo- 
ratory Technician training will attend the 15- week 
course conducted by the U.S. Army at the Academy of 
Health Sciences, Fort Sam Houston, Texas. There will 
be 10 classes conducted per year and it is anticipated 
that 175 Navy Hospital Corpsmen will attend the pro- 
gram in FY-80. Prerequisites required for this training 
remain as detailed in the Catalog of Navy Training 
Courses (CANTRAC), NAVEDTRA 10500. 

The Armed Forces Institute of Pathology (AFIP), at 
Walter Reed Army Medical Center in Washuigton, 
D.C. will serve as the Tri-Service training site for Ad- 
vanced Histology Technician training commencing 
early FY-80. Classes, 20 weeks in duration, will be con- 
ducted twice yearly. This program replaces on-the-job 
training for Navy Advanced Histology Technicians. 

Individuals must be graduates of the Basic Labora- 
tory Technician (8501) program, or possess acceptable 
equivalent experience, to qualify for assignment to the 
8503 training program. Complete information on the 
program is being provided in the near future. 

Personnel desiring to attend Navy Medical Depart- 
ment advanced specialty training programs should sub- 
mit their applications in accordance with the provisions 
of BUMEDINST 1510. lOD. 


On 31 March 1979 the U.S. Naval Hospital, Roosevelt 
Roads, Puerto Rico disestablished the Branch Clinic 
located at the U.S. Naval Facility, Barbados, West 


The Naval Hospitals at Port Hueneme, Annapolis, 
Quantico, and Key West will be closed and replaced 
with outpatient clinics according to the recent Shore 
Establishment Realignment announced by SECNAV on 
29 March. The SER will go into effect 1 June, 

Surgeon General Honored 

The American Medical Society on Alcoholism, a 
component of the National Council on Alcoholism 
Inc. recently presented a medal to VADM Willard 
P. Arentzen commemorating his ". . . outstand- 
ing contributions to the advancement of knowl- 
edge about alcoholism and in grateful recognition 
of unstinting dedication to healing the sick and 
troubled victims of this illness." 

CAPT Joseph Zuska, MC, USN {Ret.) presents award. 

Volume 70, May 1979 

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